- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.32 / $895.57 / $1,558.90
| Professional | | $637.32 | $895.57 | $1,558.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.56 / $2,056.23 / $3,291.72
| Professional | | $1,121.56 | $2,056.23 | $3,291.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.69 / $2,435.28 / $3,664.33
| Professional | | $1,394.69 | $2,435.28 | $3,664.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.73 / $2,057.42 / $3,296.91
| Professional | | $1,229.73 | $2,057.42 | $3,296.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.49 / $2,534.19 / $6,292.48
| Professional | | $1,152.49 | $2,534.19 | $6,292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.49 / $2,195.69 / $3,677.05
| Professional | | $1,152.49 | $2,195.69 | $3,677.05 |